Surgical safety checklists save lives

The use of surgical safety checklists before, during and after surgery helps reduce adverse events due to human error and accompanying complications that may lead to death.

This was the conclusion of a 2009 international study called "A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population," published in the New England Journal of Medicine as part of the World Health Organization's Safe Surgery Saves Lives program. The study was performed in eight cities across the globe, representing a variety of economic circumstances and diverse patient populations.

The study used a 19-point checklist designed to improve team communication and consistency of care for patients undergoing non-cardiac surgery. It concluded that the rate of death declined from 1.5 per cent before the checklist was introduced to 0.8 per cent afterward. Inpatient

complications went from 11 per cent to seven per cent after the introduction of the checklist.

"It was this study that prompted everyone to implement the checklist," said Chantal Gagné, nurse educator, operating room and ophthalmology, North Bay General Hospital (NBGH).

NGBH implemented the surgical safety checklist January 25th. The World Health Organization has recommended its use, and Accreditation Canada and the Ministry of Health and Long-Term Care (MOHLTC) have mandated it.

Accreditation Canada, an independent organization that provides external peer reviews to assess hospitals, has made it a "required organizational practice."

"If we don't have it in place, we may not receive our accreditation, which could affect funding," said Gagné, 15-year veteran registered nurse with seven years of perioperative experience.


July deadline

The MOHLTC has added the checklist to the patient safety indicators, which are reportable to the public to maintain transparency in Ontario's hospitals. By July, all hospitals will be required to report compliance rates for surgical safety checklists.

Gagné equates the list to what pilots use in aviation. "They are all things we've done, but we are just putting it in a checklist," she said.

One of the ways she was able to get the staff to accept the idea of using a list was by asking: "If you or your loved one was having surgery, would you want the surgical team to use a surgical safety checklist?"  The unanimous answer was "yes."

Gagné then spent about three months educating staff, providing information sessions and obtaining feedback on how the staff felt it should work. A standard 26-point surgical checklist is available on the Canadian Patient Safety Institute website, although it is recommended that users customize it to each hospital's work environment.

"We wanted to get input from physicians, surgeons, anesthetists, nurses, and lab and infection control staff on what should go into the checklist, so in the end, they own it," Gagné said.

Other awareness materials such as posters were produced for surgeons' offices and surgical areas to inform patients.

"We did all the work we could do, including making it policy," Gagné said. "Education beforehand was important to make them aware, but also to allow them to assimilate the change."


Three steps

The team is briefed before anesthesia is administered, allowing the patient to ask questions. This is referred to as the "sign-in."

The second step is a "time out" before skin incision. At this stage in the process, the team inspects the surgical site and confirms that antibiotics have been given.

The third step is a "sign out" or debriefing before the patient leaves the operating room. "We review what happened during the surgery and talk about any post-operative concerns for the patient in terms of pain management, antibiotics or anticoagulation."

One of the challenges was gathering the team together at the right time and the right place for the "sign in" phase so there are no delays in using the surgical rooms.

Gagné said the staff are adjusting well and their feedback is being heard.

Patient response has also been positive.

Once the system is fully established, spot-check audits will be performed to ensure compliance and to give feedback to the staff who are using it. The global study indicated that use of the checklist should result in fewer incident reports.

"I think we're getting better at putting things in place that make patients less vulnerable to errors," Gagné said.


www.nbgh.on.ca